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Quick QOF tips, 2013-14: Heart failure

Dr Simon Clay explains the 2013/14 changes to heart failure (HF) indicators

This article looks at coding in heart failure for the QOF - in particular the changes that were implemented in version 25.0 of the ruleset (April 2013).

HF 1

This indicator is fairly self-explanatory and simply requires practices to have a register of heart failure (HF) patients. All the expected Read codes are valid including the entire G58 Read code chapter, as well as any patient who has a Read code of the New York Heart Association classification of HF in their records.

HF2

This indicator requires that any patient alleged to have HF which was coded after 1 April 2006 has had an echocardiogram to prove it. This has to be coded no earlier than three months before the HF code date and no later than one year afterwards.

In fact HF patients don’t actually need an echocardiogram itself to score HF2 because, in addition to the valid echocardiogram Read codes of which there are seven, the patient also scores HF2 if they are coded as:

  • having had an echocardiogram requested
  • having had a coronary angiogram planned or done (as long as it wasn’t normal)
  • having had an MR angiogram, or even just
  • referred to a cardiologist, or a cardiology GPSI.

These codes must also be within the required time frame above.   

HF3 and HF4

A critical piece of knowledge in managing the heart failure ruleset is the additional coding that has to be present (if appropriate) in the patient’s record to define the patient’s HF as ‘heart failure due to left ventricular systolic dysfunction (LVSD).’  This is because not all HF is due to LVSD, but the QOF only requires us to treat with an ACE inhibitor or ARB if the HF is due to LVSD and only requires us to give beta blockers if the HF is due to LVSD and the patient is also treated with an ACE inhibitor or ARB as well.

Remember:

  • HF3: ‘Patients with HF due to LVSD need an ACE inhibitor or ARB.’
  • HF4: ‘Patients with HF due to LVSD who are prescribed an ACE or ARB also need to be prescribed a beta blocker licensed for HF.’

Definitions

There is a set of codes that signify that a patient has HF under the QOF.  These are as follows:

HF codes

  • G58.. Heart failure
  • G580. Congestive heart failure
  • G5800 Acute congestive heart failure
  • G5801 Chronic congestive heart failure
  • G5802 Decompensated cardiac failure
  • G5803 Compensated cardiac failure
  • G581. Left ventricular failure
  • G5810 Acute left ventricular failure
  • G582. Acute heart failure
  • G584 : Right ventricular failure (Version 23.0 Oct 2012)
  • G58z. Heart failure NOS
  • G1yz1 Rheumatic left ventricular failure
  • 662f. New York Heart Association classification - class I (v9)
  • 662g. New York Heart Association classification - class II (v9)
  • 662h. New York Heart Association classification - class III (v9)
  • 662i. New York Heart Association classification - class IV (v9)

Then there are two codes that additionally define the patient as having LVSD.  This is a change to the QOF rules since version 25.0 (1 April 2013). These are:

HF due to LVSD codes

  • G5yy9  Left ventricular systolic dysfunction
  • 585f.    Echocardiogram shows left ventricular systolic dysfunction

Changes in the QOF definition of HF due to LVSD

It is important to note that the rules for defining HF due to LVSD changed in April 2013 (version 25.0 of the ruleset).  

Now, if an HF patient has only a Read code from list one, then they will not be classified as having HF due to LVSD. This means they will not be in the denominator for HF3 or (if the patient is prescribed an ACE inhibitor or ARB) in the HF4 indicator either.

So patients who are already on an ACE inhibitor or ARB will not count for HF3, even if they do in fact have HF due to LVSD (and even if they counted under last year’s QOF rules). To ensure that such patients are looked at by the QOF rules, they must have one of the two trigger codes to define LVSD listed above in their record.

Previously there was a smaller set of codes that defined the patient as having HF due to LVD dysfunction. These were:

  • G581. Left ventricular failure
  • G5810 Acute left ventricular failure
  • 585f. Echocardiogram shows left ventricular systolic dysfunction
  • 585g. Echocardiogram shows left ventricular diastolic dysfunction
  • G5yy9 Left ventricular systolic dysfunction
  • G5yyA Left ventricular diastolic dysfunction

Simply having one of these codes in the record ensured that the patient was included in the denominator group for HF3 and HF4. This is no longer the case.

The consequence of these LVSD changes is that if (for example) you have a patient who had an echocardiogram several years ago which did show LVSD, but you coded the patient at that time with, for example, a G581 code (‘left ventricular failure’) or with G5810 (‘acute LVF’) but did not also add one of the two new trigger LVSD codes, then the patient will not officially have HF due to LVSD any more.

They won’t score against you if they are not on an ACE inhibitor, ARB or a beta blocker, but they won’t score for you under HF3 or HF4 if they are.

This can either be an advantage (if your patient is 98 and you judge that clinically the risks of the drugs outweigh the benefits) or a disadvantage if this patient has already been started on those drugs but you are not getting the credit under the QOF analysis.

In addition, if you have prompting software to remind you of QOF requirements, patients who do not have in their record a trigger code for HF due to LVSD will not get those prompts for ACE inhibitors and for beta blockers as they won’t fulfil the QOF definition of patients with HF due to LVD.

All patients in your HF register who have any of the codes which previously defined them as having LVSD probably need to have added one of the two new trigger codes for LVSD. Otherwise, their scripts for ACE inhibitors and for beta blockers won’t benefit your QOF scores.

By understanding this, you can choose (or not) to add codes which define the patient as having plain HF or HF due to LVSD. Understanding this enables the practice to give an accurate representation of the clinical situation as well as maximising patient care and practice profits too.

Dr Simon Clay is a GP in Erdington, Birmingham

Click here for Dr Clay’s comprehensive QOF Resource disc

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